If it can’t get any worse, it can only get better—whatever “it” may be. In the case of societal acceptance and public perception of proton beam therapy—especially with respect to its use for prostate cancer—it’s been pretty bad.
Based on negative media coverage, insurance denials, and lack of even a mere mention by many physicians, a newcomer would have to conclude that proton beam therapy is the black sheep of cancer treatment technology. It’s too expensive, eternally experimental, and never ever medically necessary—or so they are led to believe.
This message has been blasted loudly and repeatedly for years. The result is the intended negative impact on the public’s general understanding of and access to proton therapy. Many, or maybe even most people still mistakenly believe it to be too costly, too risky, and certainly too confusing to consider. But this sad situation may be on the verge of changing.
After all, how much worse can it get?
Let’s examine the position of proton’s pendulum of perception with respect to insurance, media, and physicians. Then we can estimate its likely trajectory in the coming years.
The insurance bandwagon
In recent years things have actually worsened for proton. Just five years ago Blue Cross Blue Shield of South Carolina covered my proton beam therapy at the University of Florida Health Proton Therapy Institute. Today they would not. Four years ago Cigna covered proton for my friend and coworker. Now they would not. And of course, the list goes on.
… the proton denial of coverage bandwagon—maybe more appropriately called badwagon—has been rolling along, gaining a little push as each new rider hops on board.
Yes indeed, the proton denial of coverage bandwagon—maybe more appropriately called badwagon—has been rolling along, gaining a little push as each new rider hops on board. But alas, the wagon has become crowded and heavy. With fewer new recruits to help keep it merrily moving uphill, it must necessarily lose momentum, slow down, and ultimately begin rolling backward.
Furthermore, conspicuously absent from the passenger list is Medicare. It may be the only insurer—or at least the most visible one—still walking, if not marching to the beat of its own drummer. Whatever you or I may think about Medicare in general, that institution has thankfully resisted any temptation to adopt an anti-proton stance, even for prostate cancer. 
Because its over-65 demographic includes a large number of prostate cancer patients, it seems at least somewhat improbable that it would run the risk of instantly alienating so many Americans, especially in the context of trying to make us feel good about government’s increasing involvement in health care (a topic deserving its own post).
Although we can say “so far, so good” with Medicare now, we also have to acknowledge that the future is always uncertain. We have to wonder: where will we go from here? How will the insurance landscape change?
For the sake of argument and simplicity let’s assume every private insurance carrier now has an anti-proton stance and only Medicare remains supportive. What can happen next? Short of complete nationalization of our entire health care system, there are three main scenarios: (1) Medicare suddenly shifts gears (unlikely, as stated above) and follows the lead of the private carriers? (2) Medicare continues as-is, and all private carriers forever maintain their anti-proton position? Or (3) one of the no-go-proton bunch eventually finds a reason to be first to fall off the bad boys’ bandwagon?
Facts, after all, are facts. The cost of proton is falling, the database supporting proton is growing, the number of facilities is rapidly rising, and the demand for proton is increasing.
The third option seems not only most likely, but inevitable. Ultimately, reality will become undeniable. Facts, after all, are facts. The cost of proton is falling, the database supporting proton is growing, the number of facilities is rapidly rising, and the demand for proton is increasing. The temptation to differentiate from other private carriers by covering proton will gradually reach a level where one wise company will change its policy—not as a humanitarian gesture, but as a sensible business decision. When that happens, others will have to reconsider as well.
The pendulum will have begun changing direction.
Media madness
And what about all the relentless negativity in the press over the years? It has certainly taken its toll, but it’s becoming a bit boring in its monotony. Does anyone really want to read another article by the Wall Street Journal’s Melinda Beck, mercilessly blasting proton?
Times are changing, and so is the tone of media’s coverage of proton. There’s just too much good news to ignore. Even the Wall Street Journal has finally put a happier face on proton therapy—not, of course, in Beck’s health column, but in their business section.
In the very first paragraph of a recent WSJ article, Denise Roland refers to “the explosive rise of proton-beam therapy.” She accurately explains that “unlike traditional radiotherapy … protons … deposit most of their energy in the tumor, minimizing damage to surrounding, healthy tissue.” She refers to the doubling number of proton beam treatment rooms, the development of cheaper compact centers, and the increase in demand—not portrayed as evil, wasteful, squandering of resources, but as positive developments in the treatment of cancer.
Roland’s article not only avoids Beck’s consistently negative spin, but is eerily close to having a decidedly positive spin. She refers to the recent development of pencil-beam scanning as a “breakthrough” for proton. She mentions a Belgian hospital adding a proton facility in order to make the hospital “part of the club.” Imagine that—actually wanting to be in the proton “club” and enjoying positive media coverage because of it! She quotes the head of that hospital as further explaining their need “to make sure we remain ahead of others.” Right! Proton is leading edge.
Roland … mentions a Belgian hospital adding a proton facility to make the hospital “part of the club.” Imagine that—actually wanting to be in the proton “club …”
There are a growing number of facilities sharing that view, which is not really surprising because (again) it’s based on the undeniable truth. What is surprising is the trend toward positive portrayal of proton therapy in the Wall Street Journal and other news sources. Some stories are technical in nature, while others seek a broader audience by framing the topic as a human interest story from the patients’ viewpoint. The narrative has become one of wronged patients using legal means to fight back, foreign patients coming to the United States for proton treatment, and medical miracles courtesy of protons—especially in pediatrics.
Physicians positions
Ultimately, physicians will have the greatest impact on changing proton’s trajectory. As a group, they will unavoidably become more pro-proton, more frequently citing it as the best treatment for many cancers. They will even begin applying the magical “medically necessary” phrase more often, paving the way for easier insurance approvals.
Why is the pro-proton contingency of physicians certain to grow? Because more doctors and medical personnel will necessarily be practicing at or employed by the many new proton centers. The rapidly growing number of facilities will provide irresistible opportunities (i.e., jobs) for doctors, nurses, radiation therapists, and other medical professionals to become involved in an exciting, effective, cutting edge field. And just as the chef at a gourmet Italian restaurant would understandably be enthusiastic about the pasta they serve, we can expect a doctor practicing at a proton center to support the appropriate use of the proton therapy they provide.
The biggest challenge for proton therapy has arguably been its omission from mention.
The biggest challenge for proton therapy has arguably been its omission from mention. When a diagnosis is given by a trusted doctor and proton is not even on the list of treatment options to consider, proton—and perhaps the patient—loses by default. When more doctors are involved in proton therapy, when more centers are locally convenient, and when proton is more often on the list, the pendulum will gain momentum in the positive direction.
What about prostate cancer?
The greatest resistance for the use of proton therapy has been in the treatment of prostate cancer. One in six or seven men will be diagnosed with it. That adds up to a lot of people, a lot of money, and a large incentive to push those men into alternative therapies that might not be as good. There are, after all, many ways to treat prostate cancer, and it has certainly been convenient to claim proton is just not necessary for that particular flavor of cancer.
But it’s going to become increasingly difficult and less convenient to continue that attitude. As the benefit of proton’s precision is more loudly proclaimed in the context of non-prostate cancers, it is going to become glaringly obvious that the same precision applies in the same way to treating a prostate.
You don’t need a medical degree to understand that zapping a brain tumor is safer if the brain or maybe the eye beyond the tumor is not also radiated.
You don’t need a medical degree to understand that zapping a brain tumor is safer if the brain or maybe the eye beyond the tumor is not also radiated. Similarly, it makes intuitive sense that radiating a breast tumor—especially left breast—is safer if the radiation stops before reaching the lung or heart. Only proton radiation—not conventional x-ray/photon radiation—can do that, and so it is lauded now more than ever as the uniquely precise tool that it is.
But then why, people will eventually ask themselves, is this precision oddly not helpful in the treatment of prostate cancer? Do we not care about sparing the nerves surrounding the prostate that are responsible for erectile function? Are we unconcerned that radiating the nearby bladder could contribute to urinary incontinence? Have we chosen to ignore the risk of secondary cancers that might be increased by needlessly radiating healthy tissue beyond the prostate tumor? Certainly not if you happen to be the one with the prostate cancer—and there are a lot of us.
Broader acceptance of proton beam therapy for prostate cancer may not necessarily be the first milestone reached along its road to recovery, but as that road is traveled we’ll get there eventually. The writing is on the wall, and the world is waking up.
And the proton pendulum will swing.
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